eMedicine Specialties > Emergency Medicine > Pulmonary

Pleural Effusion: Follow-up

Author: Fredrick Melik Abrahamian, DO, FACEP, Associate Professor of Medicine, University of California at Los Angeles School of Medicine; Director of Education for Emergency Medicine Residency Program, Consulting Staff, Department of Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Contributor Information and Disclosures

Updated: Jan 14, 2008

Follow-up

Further Inpatient Care

  • The patient condition and the cause of effusion dictate whether admission to a regular floor or ICU is required. Consultations with pulmonary specialists or surgeons in the ED may facilitate level-of-care issues.
  • For some patients, definitive treatment may include serial thoracenteses, instillation of fibrinolytic agents (eg, streptokinase, urokinase), chemical pleurodesis (eg, doxycycline, bleomycin, talc), pleuroperitoneal shunt placement, intrapleural administration of talc during thoracoscopy, systemic chemotherapy, or mediastinal radiation.

Further Outpatient Care

  • Arrange for follow-up with the patient's primary care physician or a pulmonary specialist within 2-3 days, especially if thoracentesis is deferred.
  • If early follow-up seems unlikely, give the patient clear instructions to return to the ED in 2-3 days for reevaluation.

Inpatient & Outpatient Medications

  • When parapneumonic effusion is suspected, initiate antibiotics as soon as possible, preferably in the ED.
  • Outpatient therapy depends on the cause of the effusion.
  • Consult a social services professional when a patient cannot afford medications.

Transfer

  • If the usual criteria for stability are satisfied, patients may be transferred to another facility for definitive care.
  • If thoracentesis is performed, a follow-up chest radiograph must be obtained to rule out pneumothorax before discharging the patient.
  • With iatrogenic pneumothorax, chest tube placement is indicated, and close follow-up is necessary. Stable patients may be transferred by ground with proper personnel and chest tube in place.

Deterrence/Prevention

  • Strict precautions are required in the handling of needles and bodily fluids, including pleural fluid.
  • Reports exist of HIV transmission from needles contaminated with pleural fluid.

Complications

  • Delaying antimicrobial therapy for parapneumonic and other effusions, when antimicrobial therapy is indicated, potentially increases the risk of developing empyema, pulmonary fibrosis, and sepsis.

Prognosis

  • Prognosis varies and depends on the cause and characteristics of the pleural effusion.
  • Patients who seek medical care earlier in the course of their disease and those with prompt diagnosis and treatment have a substantially lower rate of complications than those who do not.

Patient Education

Miscellaneous

Medicolegal Pitfalls

  • Failure to recognize effusion by not obtaining chest radiographs or misdiagnosing effusions as pleural thickening or parenchymal infiltrates
  • Incorrect presumption that the pleural effusion is old and unchanged
  • Failure to recognize potential life-threatening conditions such as pulmonary embolus, esophageal rupture, hemothorax, empyema, and strangulated diaphragmatic hernia
  • Unnecessary attempts to perform thoracentesis
  • Removal of large amounts (>1000 mL) of pleural fluid with subsequent development of reexpansion pulmonary edema
  • Causing complications of thoracentesis, such as pneumothorax or laceration of intra-abdominal organs
  • Insertion of chest tube in the presence of a malignant tumor that obstructs a mainstem or lobar bronchus
  • Transferring a patient to another hospital without excluding pneumothorax after thoracentesis
 


More on Pleural Effusion

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Differential Diagnoses & Workup: Pleural Effusion
Treatment & Medication: Pleural Effusion
Follow-up: Pleural Effusion
Multimedia: Pleural Effusion
References
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References

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Further Reading

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Keywords

pleural fluid, transudative effusion, exudative effusion, thoracentesis, congestive heart failure, bacterial pneumonia, pulmonary embolus, cirrhosis, chronic pancreatitis, collagen vascular disease, tuberculosis, yellow nail syndrome, malignant mesothelioma, rheumatoid effusions, pleural friction rub, hydrothorax, hemothorax, chylothorax, pyothorax, empyema

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Contributor Information and Disclosures

Author

Fredrick Melik Abrahamian, DO, FACEP, Associate Professor of Medicine, University of California at Los Angeles School of Medicine; Director of Education for Emergency Medicine Residency Program, Consulting Staff, Department of Emergency Medicine, Olive View-University of California at Los Angeles Medical Center
Fredrick Melik Abrahamian, DO, FACEP is a member of the following medical societies: American College of Emergency Physicians, Emergency Medicine Residents Association, and Infectious Diseases Society of America
Disclosure: Nothing to disclose.

Medical Editor

Michael S Beeson, MD, MBA, FACEP, Professor of Emergency Medicine, Northeastern Ohio Universities College of Medicine; Program Director, Emergency Medicine Residency, Summa Health System
Michael S Beeson, MD, MBA, FACEP is a member of the following medical societies: American College of Emergency Physicians, Council of Emergency Medicine Residency Directors, National Association of EMS Physicians, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Pharmacy Editor

Francisco Talavera, PharmD, PhD, Senior Pharmacy Editor, eMedicine
Disclosure: Nothing to disclose.

Managing Editor

Paul Blackburn, DO, FACOEP, FACEP, Program Director, Department of Emergency Medicine, Maricopa Medical Center; Assistant Professor, Department of Surgery, University of Arizona
Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association
Disclosure: Nothing to disclose.

CME Editor

John D Halamka, MD, MS, Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center
John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine
Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH, Professor and Chair, Department of Emergency Medicine, University of Virginia Health System
Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society
Disclosure: Nothing to disclose.

 
 
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